Improve DP with interdisciplinary focus

Hospital's LOS declined significantly

A regional hospital in a Southern rural state found that its hospital discharge process improved when the institution focused on refining its goals and improving collaboration between disciplines.

"About four years ago, our administration made the decision to refine our goals and bring our goals closer to what people at the bedside provided in care," says Angie Roberson, RN, BSN, CPUM, director of case management at Spartanburg Regional Medical Center in Spartanburg, SC.

For instance, the administration changed and enhanced the length of stay (LOS) goals, she says.

"All of a sudden, it gave me the opportunity to step through some new doors," Roberson says.

"What was interesting is right off the bat, I had a nurse manager say, 'I guess you feel a lot of pressure now that LOS is a goal,'" she recalls. "I said, 'I do feel pressure, but you should feel it too because length of stay is a shared goal.'"

The nurse manager's initial response was an eye-opener for Roberson.

"I realized I had a lot of work to do," she says.

As a result of the project to improve discharge planning, the hospital's length of stay has steadily declined from a baseline of 5.9 days for a severity-adjusted Medicare population to 4.68 days, Roberson says.

"We're a trauma center and major referral for small hospitals in our region," she adds. "So we get all trauma cases and cardiac surgeries, and we don't just take short LOS kinds of things."

The LOS decrease is a testament to the collaborative spirit and work across the hospital system, Roberson says.

"It doesn't just happen in nursing and case management," she adds. "We also work with radiology and other departments, and as soon as we identify a glitch in the system, we go to that department and say, 'We saw this happen,' and then they'll work collaboratively with us."

There already had been some collaboration in discharge planning since different disciplines were seeing patients, and case managers were talking to everyone involved and putting together a good discharge plan, Roberson says.

"But we really didn't have the buy-in and true interdisciplinary collaboration that was needed at all levels," she explains. "It became evident that it was something I had to work on, so it could become a culture change."

Managers cannot force people to collaborate. It has to be something that evolves as employees' work culture evolves, she adds.

"We made this part of our strategic goals, and we have a monthly report card that goes out to staff, and we use that as our springboard," Roberson says.

Roberson began by speaking with the vice president of nursing and the vice president of quality, case management, and perioperative services.

"I said, 'This is what I see; here are my ideas, and this is what I'd like to do to create a nursing and case management collaboration," she says.

"Case managers were part of the nursing unit, although they don't report to the nurse manager and instead report to case management," Roberson explains. "But their work space is on the nursing unit, so I needed their buy-in and support."

Roberson suggested a theme they called "the power of nursing and case management collaborating."

"First and foremost, we were having interdisciplinary rounds on the unit twice a week," Roberson says. "We were having conversations we were bringing nursing into, and we were suggesting that every morning the charge nurse and case manager have a 15-minute huddle, reviewing their plans for the day."

Also, once or twice a week, they would discuss difficult cases on the unit, bringing in physical therapy, occupational therapy, nutrition, and sometimes the physician to help identify roadblocks and how everyone could work together to best resolve the issues, she adds.

"We were changing the case management model," Roberson notes. "We were moving away from a model where case management on the unit did everything, including governmental utilization review and discharge planning."

The utilization review portion of the workload was suffering, because it was left to the least experienced staff, she says.

"That wasn't acceptable," Roberson says. "I knew more and more scrutiny would be placed on medical necessity."

One main cause of the problem was that the discharge process had become so complex, and the utilization review process had become complex, she adds.

The organization tackled the problem by separating the roles case managers typically had and dividing these into the duties performed by a nurse case manager, who would do the utilization review and initial assessment, and the discharge planning case manager, who is a social worker or nurse, Roberson says.

"Staff members wanted to do all of the pieces, but the problem was the priorities were conflicting, and so it was a no-win situation when you had the combined role," Roberson says. "It was a problem of conflicting roles, and the size of our facility wasn't conducive to that model anymore."

Although the seven-year-old case management model had worked well when initiated, health care is constantly evolving, and models should change too, she adds.

"What I told our staff was that we'd hit the backspace button one time and split the role apart," Roberson says. "I wanted to use this opportunity to kick off a collaboration between nursing and case management."

The key was to help nurses understand the changes and how it would impact them.

"I also knew that if we were going to be successful with our length of stay goals, I needed nursing and case management to work like a well-oiled machine," Roberson says. "I needed them to understand that we're a team, and we need each other to be successful for our goal."

Both the vice president of nursing and the vice president of case management agreed with this goal and helped promote the change.

"So, we had a kick-off and invited every case manager and charge nurse and clinical nurse educators who were responsible for education in our division to attend a lunch in a large auditorium," Roberson says. "We played the song 'Life is a Highway' because this was a journey, and we wanted them to see we were on a road and heading somewhere exciting."

Every nursing unit was represented, and the entire case management team attended, she adds.

The two vice presidents, along with Roberson, spoke at a two-hour session, first having attendees divide into small groups to engage in an ice-breaker exercise.

"Then I explained what was happening in case management and why it was happening," she says. "We explained some of the things we wanted to happen — like the daily huddles — where we wanted to include our communication to the patient in preparation for discharge."

For example, case managers and nurses will say this to a congestive heart failure patient: "We expect you'll probably be here three to four days, and our goal is to get you back on track as soon as possible," she explains.

Roberson also explained to case manager nurses that these changes were part of the hospital's strategic goals, including the goal to provide quality care for patients.

The kick-off session had its intended effect: The next day, the staff began to hold the huddles and communicate more effectively.

About nine months into the project, Roberson attended a meeting attended mostly by nurses, and the discussion centered around the discharge process.

"One nursing unit was still struggling and hesitant to accept things happening on the other units," she recalls.

But Roberson and other leaders didn't have to explain the project to the struggling unit, because the other nurse managers who had made the change successfully spoke up and quizzed them, asking, "Are you having huddles every morning? These are the ways we have become successful on our unit..."

The key is to embrace collaboration, Roberson suggests.

"Through this process, we've also been able to improve collaboration and relationships with dietary, dietitians, therapists, and all occupational therapy and speech/language pathology," she adds. "We've increased communication between all therapies."


For more information, contact:

• Angie Roberson, RN, BSN, CPUM, Director, Case Management, Spartanburg Regional Medical Center, 101 East Wood Street, Spartanburg, SC 29303. Telephone: (864) 560-6649; email: